Prisons can be violent, isolating and frightening, which can often lead to many imprisoned developing physical and mental health conditions.

Despite this, people in prison can find it more difficult to access healthcare professionals and receive high quality treatment, even when in extreme need of help. 

Provision of prisoner healthcare transferred from the Scottish Prison Service (SPS) to the NHS in 2011, with an aim of increasing access to an improved variety of specialist services and clinical expertise, as well as allowing smoother access to community-based services upon release.

However, Toni Groundwater, Head of External Engagement, Families Outside, told MSPs that these aims have not been realised:

“We heard [in the informal sessions] of the difficulty in term of accessing basic healthcare in prison, as well as significant problems in continuity of care upon release. In many cases it has led to serious and traumatic consequences, all of which were felt to be avoidable if treatment and better joined-up approaches had been provided.

“We’ve heard instances of medication not being made available for people with existing conditions on arrival in prison. Hospital appointments missed due to shortage of staffing and escorts not available. We heard of someone missing multiple visits to hospital in relation to a leg injury resulting in long term disfigurement and ongoing problems. And we continually hear about long waiting times to receive support.”

Families Outside is a Scottish charity working on behalf of families of those in prison to decrease inequalities. They would like to see parity between justice and health agencies and for families of people in prison to be recognised as carers with significant and valuable information to contribute.

Many prisoners have experienced physical, emotional, or sexual abuse while being in imprisonment and others have been imprisoned with already existing health issues, the most common being bipolar disorder and schizophrenia.

A Scottish Prison Service (SPS) spokesperson said:

“Our front-line prison officers and NHS staff work extremely hard every day to provide appropriate care and support to those in our care.

“Strong partnerships exist between SPS and NHS prison healthcare, with good working relationships and collaborative practice evident across all establishments.

“However, we recognise that more can be done and there is a shared commitment to achieving that.”

There are 15 prisons in Scotland, with the majority managed by SPS, with the exception of HMP Addiewell and HMP Kilmarnock which are run by Sodexo and Serco respectively.

Drugs and Alcohol

In 2017, the Alcohol Use Disorders Identification Test (AUDIT) was administered to prisoners as part of the Scottish Prisoner Survey conducted by SPS.

A report on this test from the Scottish Public Health Observatory shows that, of those prisoners who completed the AUDIT assessment, 63% had an alcohol use disorder, with almost a third classed as possibly alcohol-dependent.

According to the AUDIT report, 27% were considered hazardous drinkers causing significant risks of possible harmful consequences and 6% were harmful drinkers which had both physical and mental health consequences from consuming alcohol. Overall, these statistics were considered to be slightly better than in 2015.

Within this same cohort of prisoners assessed under AUDIT, two in five people were under the influence when they were arrested and almost half were under the influence of drugs.

When assessed in prison, 39% had used illegal drugs while imprisoned – with 28% having used them in the past month at the time of taking the AUDIT survey. The three most common drugs used were cannabis – used by half of the cohort – and then benzodiazepines, used by 46% of people surveyed and subutex, by 45% of the people surveyed.

Public Health Scotland recently launched its drugs early warning system, RADAR, and highlighted that new benzodiazepine street drugs are of growing concern in Scotland. For example, etizolam was first identified in 2012 and has now become one of the highest contributors to drug-related deaths in Scotland.

One in four episodes of psychosis in prison are related to intoxication or withdrawal from substances, according to the AUDIT.

Mental Wellbeing

The Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS), the Scottish Health Survey (SHeS) and the Scottish Prisoner Survey showed on average mental well-being is significantly lower among people in prison.

Prescribing indicators found that 14% of prisoners had a psychiatric history and just over half of those had a history of self-harm, including attempted suicide.

A survey in 2021 by Mental Welfare Commission for Scotland found that more than three quarters of prison staff reported concerns about the provision of mental health support within prison. Out of 107 prisoners who spoke to the Mental Welfare Commission, 81% reported addiction to alcohol or drugs.

There were 371 deaths in prison custody in 2021, with 54 resulting from suicide, which has grown in recent years.

Moreover, 89% of prison staff reported they wanted more basic training in mental health and more in-depth training to benefit the increasing number of prisoners with complex mental health needs and presenting behaviours.

Among prisoners, 23% of those who had been receiving mental health support at the time of the survey said their GP had been in the process of referring them to mental health services before they entered custody.

Treatment

Public Health Scotland released a report in April showing the waiting times for treatment for drug and alcohol misuse in prison between October and December 2021. Of the 327 people, 86.2% had to wait up to one week following referral and 97.8% of people were seen in three weeks or less overall. 

Data is collected twice a year by The National Prison Care Network on the number of prisoners prescribed opiate replacement/substitution therapies. In 2020, there were 8,005 prisoners in custody in Scotland on 19 February, with 1,707 (21%) of those being prescribed methadone, 170 (2.1%) being prescribed Buprenorphine tablets, and five (0.06%) being prescribed Suboxone (buprenorphine & naloxone) on that day.

At a meeting last month of the Health, Social Care and Sport Committee, Ms Groundwater from Families Outside said an IT system to keep track of prisoner’s information, such as diagnosis and drug prescription data, could be useful upon release. Currently GPs treating released prisoners do not have access to any of this information.

Ms Groundwater said:

“Often people cannot access the medication they need after being released from prison if they do not have an address, although many prisoners do not have a place to go when once their released and getting help to receive accommodation is also an issue.”

Scotland’s prison estate has evolved significantly over the years, with new prisons opened, old prisons closed, and others remodelled. However, this data suggests it may also be time to remodel the healthcare system in prisons and improve the much-needed help for the people who are imprisoned.

Read more: Lack of mental health support sad but no surprise; RADAR system to spot drug death risks; Third of carers feel unsupported, survey shows

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